Shoulder Replacement

Shoulder osteoarthritis

Dr. Marc Darrow Shoulder osteoarthritis

The shoulder is a common source of disability resulting from traumatic and degenerate tears of the rotator cuff, subacromial impingement, and osteoarthritis. Traditional non-surgical management has focused on pain-killers and anti-inflammatory medications. When these treatments fail – the next step is shoulder replacement.

More and more despite research and studies like those listed below -patients are having shoulder replacement surgery and with the increasing number of surgeries comes an expanding medical speciality of failed shoulder surgery syndrome.

The most common indications for shoulder arthroplasty (or replacement) are osteoarthritis, inflammatory arthritis, proximal humerus fractures, irreparable rotator cuff tears, rotator cuff arthropathy, and avascular necrosis of the humeral head.

In a study by radiologists, fellow radiologists are told that failed shoulder surgery risk can be reduced by looking for key imaging features that can determine the better choice of shoulder replacement – the traditional replacement or the “reverse” replacement. 1

The choice between two types of shoulder replacement

“A conventional shoulder replacement device mimics the normal anatomy of the shoulder: a plastic “cup” is fitted into the shoulder socket (glenoid), and a metal “ball” is attached to the top of the upper arm bone (humerus). In a reverse total shoulder replacement, the socket and metal ball are switched. The metal ball is fixed to the socket and the plastic cup is fixed to the upper end of the humerus.”2

Research on problems plaguing shoulder replacement

In a new study, doctors say that the reverse total shoulder arthroplasty (replacement) is an option for older patients with glenohumeral (shoulder) arthritis and a damaged rotator cuff.

However, as a semiconstrained prosthesis (limiting range of motion), conventional reverse total shoulder arthroplasty implanted in a young patient (young in this study means 50 and younger) could fail over time for many reasons beyond polyethylene wear and subsequent osteolysis (bone disintegration). To fix the plastic problem – some doctors are leaning towards metal on metal replacements.However the study documents that although metal-on-metal reverse TSA may appear to be an attractive choice in the treatment of young patients with limited reconstructive options, postoperative outcomes are disappointing, and the complication rate is high.3

The metal on metal option was seen as hopeful because of other research documenting hardware failures known to plague patients: “The longevity of total shoulder replacement is primarily limited by the performance of the ultra high-molecular-weight polyethylene glenoid component. (This study) demonstrates that glenoid component fracture associated with oxidation has not been eliminated with the advent of modern materials in the shoulder domain.” The plastic hardware problem has not been overcome.4

Another problem with shoulder replacement is a problem that stem cell therapy has been shown to fix – bone disintegration.

Again we turn to the medical research: “subchondral bone changes associated with osteoarthritis may be important factors to consider when choosing a replacement component. For surgical treatment, many implant options exist and survivability is often dependent on patient age, activity level, and progression of osteoarthritis.”5 The bone has to be repaired, grafted or strengthened to hold the replacement, even then the replacement can fail and then “the management of a failed shoulder represents represents a complex and difficult problem for the treating surgeon, with potential difficulties and complications that are related to the need to remove a well-fixed stem.”6 Good strong bone holds the replacement stem – if the replacement stem component needs to come out – good strong bone is severely compromised making revision surgery that more complex.

Shoulder osteoarthritis treatment – repairs of damaged bone and torn tissue

Doctors are looking for shoulder replacement alternatives. In one study doctors admit that surgical repairs of degenerate and torn tissue are often prone to failure and that some biological (biomedical) therapies (Platelet Rich Plasma therapy or Stem Cell Therapy) might improve  outcomes, in fact, injections of platelet-rich plasma (PRP) have led to reduced pain and improved recovery in other degenerated  areas  together with the restoration of function.7,8

Doctors in Germany looked at the options to repairing cartilage defects and soft tissue injury in the shoulder before it lead to advanced osteoarthritis. They concluded that stem cell therapy for cartilage regeneration was a minimally invasive approach for shoulder joint preservation and a alternative to shoulder replacement.9

Diagnosis of shoulder osteoarthritis

A proper diagnosis of shoulder pain is essential to determine the root cause of the problem and the proper method of treatment . This too is the subject of research: “Clinical decision making is made more difficult because of the variable presentations observed in patients with a documented full-thickness rotator cuff tear: some have good function and no pain, some have good function and pain, some have poor function and no pain, and some have both poor function and pain.”7 Treatment and treatment goals have to based on what they doctor and patient sees and discuss during the consultation and physical examination period and making a realistic determination to avoiding a shoulder replacement

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1. Lin DJ, Wong TT, Kazam JK. Shoulder Arthroplasty, from Indications to Complications: What the Radiologist Needs to Know. Radiographics. 2016 Jan-Feb;36(1):192-208. doi: 10.1148/rg.2016150055.

2. Reverse Total Shoulder Replacement American Academy of Orthopaedic Surgeons

3, Riley C, Idoine J, Shishani Y, Gobezie R, Edwards B. Early Outcomes Following Metal-on-Metal Reverse Total Shoulder Arthroplasty in Patients Younger Than 50 Years. Orthopedics. 2016 Jun 23:1-5. doi: 10.3928/01477447-20160616-05. [Epub ahead of print]

4. Ansari F, Lee T, Malito L, Martin A, Gunther SB, Harmsen S, Norris TR, Ries M, Van Citters D, Pruitt L. Analysis of severely fractured glenoid components: clinical consequences of biomechanics, design, and materials selection on implant performance. J Shoulder Elbow Surg. 2016 Jan 14. pii: S1058-2746(15)00588-1. doi: 10.1016/j.jse.2015.10.017. [Epub ahead of print]

5. Knowles NK, Ferreira LM, Athwal GS. The arthritic glenoid: anatomy and arthroplasty designs. Current Reviews in Musculoskeletal Medicine. 2016;9(1):23-29. doi:10.1007/s12178-016-9314-2.

6. Cisneros LG, Atoun E, Abraham R, Tsvieli O, Bruguera J, Levy O. Revision shoulder arthroplasty: does the stem really matter? J Shoulder Elbow Surg. 2016 Jan 25. pii: S1058-2746(15)00578-9. doi: 10.1016/j.jse.2015.10.007. [Epub ahead of print]

7. Mei-Dan O, Carmont MR. The role of platelet-rich plasma in rotator cuff repair. Sports Med Arthrosc. 2011 Sep;19(3):244-50.

8. Craig EV, Galatz LM, Sperling JW. From platelet-rich plasma to the reverse prosthesis: controversies in treating rotator cuff pathology. Instr Course Lect. 2014;63:63-70.

9. Banke IJ, Vogt S, Buchmann S, Imhoff AB. [Arthroscopic options for regenerative treatment of cartilage defects in the shoulder]. Orthopade. 2011 Jan;40(1):85-92. doi: 10.1007/s00132-010-1682-5.